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IMRT/IGRT for pelvic/abdomen cancer ESTRO course R. de Crevoisier Centre Eugène Marquis, Rennes, France October 2012, New Dehli

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Page 1: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT/IGRT for pelvic/abdomen cancer

ESTRO course

R. de CrevoisierCentre Eugène Marquis, Rennes, France

October 2012, New Dehli

Page 2: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT and IGRT for pelvic/abdomen cancer:

1. Prostate cancer: - primary tumor- after prostatectomy

2. Gynaecological cancers: - cervix carcinoma- endometrial cancer

3. Digestive cancer: - anal canal- rectum- pancreas

Exclusion of practical aspects (already presented in clinical cases)

pelvic lymph nodes+++

OUTLINE

Page 3: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT and IGRT for prostate cancer

Page 4: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT -IGRT in prostate

1.Total dose in the prostate?

2. Dosimetric benefit of IMRT (> standard 3DCRT) ?

3. Clinical benefit of IMRT (> standard 3DCRT) ?

4. Benefit of arc-IMRT ?

5. Strategies of IGRT ?

6. Clinical benefit of IGRT ?

7. New approaches of IMRT + IGRT ?

Outline

Page 5: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT -IGRT in prostate

1.Total dose in the prostate?

2. Dosimetric benefit of IMRT (> standard 3DCRT) ?

3. Clinical benefit of IMRT (> standard 3DCRT) ?

4. Benefit of arc-IMRT ?

5. Strategies of IGRT ?

6. Clinical benefit of IGRT ?

7. New approaches of IMRT + IGRT ?

Outline

Page 6: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Rational for dose escalation in

prostate cancer

Page 7: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Randomized studies showing the benefit of dose escalation (without IMRT and androgen deprivation)

Randomization

Standard dose (67-70 Gy)

High dose (76-80 Gy)

Page 8: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Randomized studies showing the benefit of dose escalation (without IMRT and androgen deprivation)

Prostate + SV70

80

Intermediate risk306GETUG 06

2010

Prostate + SV(+ AD =143 pts)

68

78

T1b-T4N0(low risk:18%, int:27%, high: 55%)

669Dutch

2008

Prostate + SV

proton

70

79

T1b-2b and

PSA<15

393Zietman

2005

pelvis(46 Gy) + boost70

78

T1-T3305Pollack,,Kuban

2000, 2002, 2008

pelvis(50 Gy) + boost

proton

67

76

T3-4

N0-N2

202Shipley

1995

VolumeDose (Gy)

TumorsNb of Pts

Standard dose (67-70 Gy)

High dose (76-80 Gy)

Page 9: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Local control

(negative biospy)

Freedom from biochemical failure

Freedom from clinical failure

Specific survival

Shipley

1995Gl 8:

19% vs 64%

No PSA available NS NS

Pollack, Kuban

2000, 2002, 200872% vs 65%

NS

PSA<10 NS

PSA>10 p=0.012

7% vs 15%

(p= 0.01)

P<0.05

Zietman

200548% vs 67%

(p<0.001)

61% vs 80%

(p<0.001)

including low risk group

NS NS

Dutch 2008 NS 45% vs 56% (p<0.001),

mainly intermediate risk group

NS NS

GETUG 06

2010NS PSA>15 p=0.03 NS NS

Median folow-up = 10 years

Randomized studies showing the benefit of dose escalation

Standard dose (67-70 Gy)

High dose (76-80 Gy)

Page 10: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Price of non-IMRT dose escalation in prostate cancer ?

IMRT -IGRT in Prostate

Page 11: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Cahlon, Seminars in Radiation Oncology 2008

Randomized studies

GETUG 06 70

80

14

22

NS .0410

18

Page 12: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Cahlon, Seminars in Radiation Oncology 2008

risk of toxicity x2

Page 13: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Strong rational for dose escalation

in prostate cancer however you

will pay a pr ice for it (if no IMRT)

Page 14: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT -IGRT in prostate

1.Total dose in the prostate?

2. Dosimetric benefit of IMRT (> standard 3DCRT) ?

3. Clinical benefit of IMRT (> standard 3DCRT) ?

4. Benefit of arc-IMRT ?

5. Strategies of IGRT ?

6. Clinical benefit of IGRT ?

7. New approaches of IMRT + IGRT ?

Outline

Page 15: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Dosimetric benefit of IMRT over 3DCRT

- concave dose distributions

- tight dose gradients

3DCRT

Page 16: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Dosimetric study comparing 3DCRT with IMRT

3DCRT:

2 lat et 4 oblique (310°, 50°, 230°,130°)

Luo, IJROBP 2006

31 pts

T1b-T2c

IMRT:

- 5 beams: 0°, 45°, 135°, 225°, 315°

- 7 beams: 0°, 40°, 80°, 120°, 240°, 280°, 320 °

Target volume : - prostate only (74 Gy)

- prostate (74 Gy) et VS (50 Gy)

Page 17: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

BLADDER RECTUM

PROSTATE only

3DRT

IMRT

V60, V70, mean: p<0.05 V60, V70, mean: p<0.05

Luo, IJROBP 2006

Page 18: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

BLADDER RECTUM

PROSTATE only

PROSTATE and SV

3DRT

IMRT

V60, V70, mean: p<0.05V60, V70, mean: p<0.05

V60, V70, mean: p<0.05 V60, V70, mean: p<0.05

Page 19: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Dosimetric benefit of IMRT in pelvis

Page 20: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

35 pts

large pelvis

(above L5-S1

)

IMRT

3D-CRT

Wang-Chesebro IJROBP 2006

IMRT versus 3D-CRT to treat the pelvis

2 LN target volumes compared (> limit): - small pelvis (L5-S1)

- large pelvis (> L5-S1, lower para-aortic nodes)

2 EBRT techniques compared: - bony landmarks 3DCRT - IMRT

Page 21: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Wang-Chesebro IJROBP 2006

IMRT improves lymph nodes coverage compared with 3DCRT

small pelvis

large pelvis

Page 22: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT decreases dose to critical structures compared with 3DCRT

Wang-Chesebro IJROBP 2006

Page 23: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Wang-Chesebro IJROBP 2006

IMRT decreases dose to critical structures compared with 3DCRT

Page 24: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT -IGRT in prostate

1.Total dose in the prostate?

2. Dosimetric benefit of IMRT (> standard 3DCRT) ?

3. Clinical benefit of IMRT (> standard 3DCRT) ?

4. Benefit of arc-IMRT ?

5. Strategies of IGRT ?

6. Clinical benefit of IGRT ?

7. New approaches of IMRT + IGRT ?

Outline

Yes, IMRT decreases significantly

the dose to the rectum, the bladder ,

the bowel and the penil bulb

Page 25: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT -IGRT in prostate

1.Total dose in the prostate?

2. Dosimetric benefit of IMRT (> standard 3DCRT) ?

3. Clinical benefit of IMRT (> standard 3DCRT) ?

4. Benefit of arc-IMRT ?

5. Strategies of IGRT ?

6. Clinical benefit of IGRT ?

7. New approaches of IMRT + IGRT ?

Outline

Page 26: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Clinical benefit of IMRT

IMRT =dose escalation toolincreasing biochemical control while not

increasing toxicity

no randomized studies comparing 3DCRT and IMRT

IMRT -IGRT in Prostate

Page 27: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Zelefsky, J Urol 2001

Low risk Intermediaterisk

High risk

86.4 Gy

86.4 Gy

Up to 86.4 Gy !!!

Page 28: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

���� 81 - 86,4 Gy

Median follow-up= 24 months (6-60)

Zelefsky, IJROBP 2002

IMRT allows dose escalation while limiting acute toxicity

Page 29: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Alicikus Cancer 2011

170 patients received 81Gy with IMRT

median follow-up =8.2 years

IMRT provides very low GI toxicity despite high dose in the prostate

Page 30: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT decreases GI toxicity compared to 3DCRT (non randomized study)

Zelefsky, J Urol 2001

3DCRT (without IMRT)

IMRT

Page 31: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Dolezel,Strahlenther Onkol 2010

IMRT decreases GI toxicity compared to 3DCRT (non randomized study)

N= 284 pts

- 3DCRT: 74 Gy (n=94)

- IMRT-seq: 78 Gy (n=138)

- IMRT-SIB: 82 Gy (2 Gy) + 73.8 (1.8 Gy) (n=52)

Page 32: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Dolezel,Strahlenther Onkol 2010

IMRT decreases GI toxicity compared to 3DCRT (non randomized study)

Grade 3 late GItoxicity

Page 33: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Cahlon, Seminars in Radiation Oncology 2008

= Low rates of toxicity despite dose escalation in the prostate

Page 34: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Cahlon, Seminars in Radiation Oncology 2008

Toxicity:

Standard dose without IMRT = High dose with IMRT

Page 35: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

51 ptsmedian age = 65 years (46–77)

All 18 patients (100%) who were potent post-operatively remained potent after RT(median follow-up = 27 months)

33 pts (64.7%) impotent after nerve-sparingprostatectomy

Bastasch IJROBP 2002, and Teh AJCO 2007

IMRTmean dose = 69.6 Gy (64.0 –72.3)

unilateral or bilateral nerve-sparing prostatectomy

Page 36: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT -IGRT in prostate

1.Total dose in the prostate?

2. Dosimetric benefit of IMRT (> standard 3DCRT) ?

3. Clinical benefit of IMRT (> standard 3DCRT) ?

4. Benefit of arc-IMRT ?

5. Strategies of IGRT ?

6. Clinical benefit of IGRT ?

7. New approaches of IMRT + IGRT ?

Outline

Yes, IMRT improves pt outcome

(local control/toxicity) thanks to dose

escalation

(in non randomized studies)

Page 37: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT -IGRT in prostate

1.Total dose in the prostate?

2. Dosimetric benefit of IMRT (> standard 3DCRT) ?

3. Clinical benefit of IMRT (> standard 3DCRT) ?

4. Benefit of arc-IMRT ?

5. Strategies of IGRT ?

6. Clinical benefit of IGRT ?

7. New approaches of IMRT + IGRT ?

Outline

Page 38: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Palma IJROBP 2008

10 pts

3DCRT IMRT VMAT

Constant

dose rate

Variable

dose rate

Static-IMRT versus VMAT in prostate ?

5-fields

74 Gy74 Gy

Page 39: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Palma IJROBP 2008

10 pts

Static-IMRT versus VMAT in prostate ?

Page 40: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Palma IJROBP 2008

10 pts

Static-IMRT versus VMAT in prostate ?

Page 41: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Ruchaud, ESTRO 2010

Clinical study

74 Gy in the prostate respecting the dose

constrains in the OAR

Clinical outcome

80 pts

80 pts

Standard IMRT

VMAT

Static-IMRT versus VMAT in prostate ?

Page 42: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Efficiency study

Treatment time/5

Ruchaud, ESTRO 2010

standard

Decrease intrafractional motion ?

Static-IMRT versus VMAT in prostate ?

Page 43: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Clinical study

Ruchaud, ESTRO 2010

CTCAE V3

� acute toxicity: relatively lowand not differentbetween the 2 IMRT modalities

Static-IMRT versus VMAT in prostate ?

Page 44: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

--Monitor Units

--Radiation delivery time

++++ (?)+++Dose distribution

VMAT“std” IMRTVMAT“std” IMRT

“Dose optimization”approach

“Time sparing” approach

Tomotherapy

intra-fraction motion / cost

« standard RT protocol » Dose escalation/painting

Static-IMRT versus VMAT in prostate ?

Page 45: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT -IGRT in prostate

1.Total dose in the prostate?

2. Dosimetric benefit of IMRT (> standard 3DCRT) ?

3. Clinical benefit of IMRT (> standard 3DCRT) ?

4. Benefit of arc-IMRT ?

5. Strategies of IGRT ?

6. Clinical benefit of IGRT ?

7. New approaches of IMRT + IGRT ?

Outline

Page 46: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IGRT in prostate: strategies

On-line

Prostate (rigid) registration

Indirect prostate visualisation

Fiducials/markers

Direct prostate visualisation

CBCT/Tomotherapy/CT on rails

Page 47: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IGRT in prostate: strategies

On-line

Prostate (rigid) registration (translation)

Indirect prostate visualisation

Fiducials/markers

Direct prostate visualisation

CBCT/Tomotherapy/CT on rails

Adaptive RT

Re-plannning

Prostate rotation

SV volume variations

Page 48: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Ahunbay IJROBP 2010

Modification of multileafcollimator leaf positions using

slice by slice registration

Court IJROBP 2005

Wi Phys Med Bio 2008

Deformableregistration basedre-optimization

IMRT

Adaptive RT: ON-line

Key issue = duration of the re-planning

…realistic ??

Page 49: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IGRT in prostate: strategies

On-line Off-line

Prostate (rigid) registration

Indirect prostate visualisation

Fiducials/markers

Direct prostate visualisation

CBCT/Tomotherapy/CT on rails

« customized »reduced PTV

few 3D imaging (before/during RT)

Adaptive RT

Re-plannning

Page 50: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Adaptive RT: OFF-line

Ghilezan, Seminars RO 2010

During RT

Hoogeman

Radiother Oncol 2005

planning CT + first 4 repeat

CT scans

Before RT

Page 51: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IGRT in prostate: strategies

On-line Off-line

Prostate (rigid) registration (translation)

Indirect prostate visualisation

Fiducials/markers

Direct prostate visualisation

CBCT/Tomotherapy/CT on rails

« customized »reduced PTV

few 3D imaging (before/during RT)

Adaptive RT

Re-plannning

If prostate rotation (outside PTV)

Prostate rotation

SV volume variations

Page 52: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Adaptive RT: hybrid OFF/ON line

Nijkamp IJROBP 2007

-1rst plan:initial 10 mm PTV margin

- new plan:6 CBCT: average CTV and rectum: 7 mm PTV margin

-Weekly CBCT for monitoring

NKI

average prostate position and rectum shape

Page 53: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IGRT in prostate: strategies

On-line Off-line

Prostate (rigid) registration (translation)

Indirect prostate visualisation

Fiducials/markers

Direct prostate visualisation

CBCT/Tomotherapy/CT on rails

« customized »reduced PTV

few 3D imaging (before/during RT)

Adaptive RT

Re-plannning

pre-treatment plan library

(SV)

Prostate rotation

SV volume variations

Page 54: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IGRT in prostate: strategies

On-line Off-line

Prostate (rigid) registration (translation)

Indirect prostate visualisation

Fiducials/markers

Direct prostate visualisation

CBCT/Tomotherapy/CT on rails

« customized »reduced PTV

few 3D imaging (before/during RT)

Adaptive RT

Re-plannning

pre-treatment plan library

(SV)

If prostate rotation

Cumulative dose

(elastic registration)Prostate rotation

SV volume variations

Page 55: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IGRT in prostate: strategies

On-line Off-line

Prostate (rigid) registration (translation)

Indirect prostate visualisation

Fiducials/markers

Direct prostate visualisation

CBCT/Tomotherapy/CT on rails

« customized »reduced PTV

few 3D imaging (before/during RT)

Adaptive RT

Re-plannning

pre-treatment plan library

(SV)

If prostate rotation

Cumulative dose

(elastic registration)

Several IGRT strategies to compensate for

anatomic var iations (from simple to more

complexe)

Does-it translate into clinical benefit ?

Page 56: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT -IGRT in prostate

1.Total dose in the prostate?

2. Dosimetric benefit of IMRT (> standard 3DCRT) ?

3. Clinical benefit of IMRT (> standard 3DCRT) ?

4. Benefit of arc-IMRT ?

5. Strategies of IGRT ?

6. Clinical benefit of IGRT ?

7. New approaches of IMRT + IGRT ?

Outline

Page 57: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Random°

Daily IGRT

Day 1,2,3 and weekly IGRT

- Quantification of prostate displacement

-Biochemical and clinicalcontrol /toxicity

- Cost (2D versus 3D and daily versus weekly)

202 pt seach arm (12% difference at 5 years ofbiochemical

control)

IGRT for prostate cancer

De Crevoisier, ASTRO 2009

Page 58: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Preliminary results

Feasibility of prostate registration

- Analysis = 107 pts (410 updated) treated by IGRT = 4078 displacements

- Median total dose = 76 Gy (70-80 Gy)

- IGRT = - Cone Beam CT (67%)- Fiducial markers (28%) - Ultrasounds (5%)

- Prostate registration performed in 94% of cases- Bone registration in 5% of cases

De Crevoisier, ASTRO 2009

Page 59: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Acute toxicity (CTCAE v.3)

Rectal Bladder

Grade 2 7% 36%

Grade 3 0% 4%

De Crevoisier, ASTRO 2009

IGRT reduces rectal toxicity

Page 60: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Chung IJROBP 2008

25 pts

10 pts 15 pts

Reducing margins thanks to IGRT and therefore toxicity

IGRT reduces rectal toxicity

73.8 Gy in the prostate

Page 61: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Chung IJROBP 2008

Dosimetric impact of reducing PTV margin

IGRT reduces rectal toxicity

Page 62: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Chung IJROBP 2008

Dosimetric impact of reducing PTV margin

IGRT reduces toxicity

Acute toxicity

/5-6

Page 63: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Chung IJROBP 2008

PTV < 5 mm ???

- delineation uncertainties

- intra-fraction prostate motion

- uncertainties in registration

Risk of mistargeting and decreased local control ?

Dosimetric impact of reducing PTV margin

IGRT reduces rectal toxicity

Page 64: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Biochemical control by RT technique (Beaumont group, 3064 pts)

Ghilezan, Seminars RO 2010

Clinical benefit of IGRT in prostate

Page 65: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Biochemical control by RT technique (Beaumont group, 3064 pts)

Ghilezan, Seminars RO 2010

Yes, IGRT reduces rectal toxicity and

may improve local control

(although clinical results are still limited)

Page 66: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT -IGRT in prostate

1.Total dose in the prostate?

2. Dosimetric benefit of IMRT (> standard 3DCRT) ?

3. Clinical benefit of IMRT (> standard 3DCRT) ?

4. Benefit of arc-IMRT ?

5. Strategies of IGRT ?

6. Clinical benefit of IGRT ?

7. New approaches of IMRT + IGRT ?- dose escalation / hypofractionation (SIB) in large target volume

- Toward dose-tumor painting (dominant lesion)

Page 67: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Bayley IJROBP 2009

N=103 pts

-Prostate delineation:CT-MRI co-registration

-IMRT in 2 sequential phases:

- P, SV and LN: 55.1 Gyin 29 fractions of 1.9 Gy

+ consecutive boost in P + SVof 24.7 Gy in 13 fractions of 1.9 Gy (=79.8 Gy)

- IGRT : intraprostatic markers

Page 68: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Bayley IJROBP 2009

IMRT in 2 phases: 55.1 Gy + 24.7 Gy (=79.8 Gy)

median follow-up = 23 months

N=123 pts

Acute toxicity

Page 69: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

PELVIC IMRT WITH SIMULTANEOUS INTEGRATED BOOST TO PROSTATE

McCammon IJROBP 2009

30 pts

Intermediate/high riskcancer

Prostate: 70 Gy in 28 fractions (2.5 Gy/fr)

Pelvic LN: 50.4 Gy in 28 fractions (1.8 Gy/fr)

+ androgen suppression

low α/β ratio for prostate cancer (=1.5 to 3)

hypofractionation

77-80 Gy

Page 70: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

median follow-up = 24 months (12–43)

McCammon IJROBP 2009

IMRT (high dose with SIB)+IGRT provides low toxicity

Page 71: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

HTT very efficient in HTT very efficient in

sparing the IC even at sparing the IC even at

dose levels < 30dose levels < 30--35 Gy. 35 Gy.

Significant sparing of Significant sparing of

rectum and bladder rectum and bladder

even at intermediateeven at intermediate--

low doses (20low doses (20--40 Gy).40 Gy).

Very low incidence Very low incidence

((≤≤ 5%) 5%) of Grade 2 acute of Grade 2 acute

GU and GI TOX. GU and GI TOX.

Disappearance of acute Disappearance of acute

G3 TOX. G3 TOX.

35 ptspelvic LN = 52 Gy

prostate = 74,2 Gy (concomitant boost)

Cozzarini, Fiorino, Radiother Oncol 2007

Intestinal cavity

Page 72: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT -IGRT in prostate

1.Total dose in the prostate?

2. Dosimetric benefit of IMRT (> standard 3DCRT) ?

3. Clinical benefit of IMRT (> standard 3DCRT) ?

4. Benefit of arc-IMRT ?

5. Strategies of IGRT ?

6. Clinical benefit of IGRT ?

7. New approaches of IMRT + IGRT ?- dose escalation / hypofractionation (SIB) in large target volume

- Toward dose-tumor painting (dominant lesion)

Page 73: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

230 patients

- Intra-prostatic lesion defined by MRIMRI (pelvic coil+spectroscopic endorectal coil) (+ 4 mm PTV)- Total Dose: - in the prostate =76 Gy in 38 fractions (2 Gy/fr)

- in the IPL= 82 Gy in 38 fractions (2,16 Gy/fr)

Fonteyne IJROBP 2008

Criteria for planning acceptance

Page 74: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

230 patients

Total Dose (to the MRI + spectroscopy-detected Intra Prostatic Lesion) =82 Gy

Grade 3 or 4 acute GI toxicity = 0Grade 3 acute GU toxicity = 7%

Fonteyne IJROBP 2008

Page 75: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Prostate registration performed thanks to fiducials

Dose-tumor painting

MRI Planning CT (VMAT) CBCT (IGRT)

Dominant lesion(+ 5mm PTV)

Peripheral zone (+ 5 mm PTV)

Prostate (+ 5 mm PTV)

Jouyaux, Cancer Radiother 2010

Dosimetric study

Page 76: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Dose-tumor painting (VMAT)

High dose in the tumor while respecting the dose constraints in the OARs (no patients treated) Jouyaux, Cancer Radiother 2010

Page 77: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Pinkawa, radiother Oncol 2010

GTV=PET = tumour-to backgroundcholine uptake ratio >2 (studies correlating choline

PET results with histopathologic examinations)

- Prostate = 66.6 Gy in 37 fractions (1.8 Gy/ fr)

- GTV-PET=83.25 Gy in 37 fractions (2.25 Gy/ fr)

(no patients treated)

Page 78: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Pinkawa, radiother Oncol 2010

GTV=PET = tumour-to backgroundcholine uptake ratio >2 (studies correlating choline

PET results with histopathologic examinations)

- Prostate = 66.6 Gy in 37 fractions (1.8 Gy/ fr)

- GTV-PET=83.25 Gy in 37 fractions (2.25 Gy/ fr)

Limiting factor for dose painting

= lack of correlation between imaging (MRI) and

pathology (tumor)

����need for studies

Page 79: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Conclusions: IMRT-IGRT in prostate

1.Total dose in the prostate?

= dose escalation (impact on specific survival)

2. Dosimetric benefit of IMRT (> standard 3DCRT) ?

= yes, in all OARs

3. Clinical benefit of IMRT (> standard 3DCRT) ?

= yes, it allows dose escalation without increasing toxicity (no randmzd st)

4. Benefit of arc-IMRT ? Time sparing/ improvement in dose distribution

5. Strategies of IGRT ? = gradient of complexity

6. Clinical benefit of IGRT ? = yes, decrease toxicity

7. IMRT + IGRT opens news approaches:

- dose escalation / hypofractionation (SIB) in large target volume

- toward dose-tumor painting (dominant lesion)

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Box technique 3D conformal EBRT IMRT

Years 1990 Years 2000 Years 2010

Arc IMRT

Image-guided RT

Functional imaging (MRI)

Registration tool

Portal imaging

TUMOR DELINEATION

DOSE DISTRIBUTION

TUMOR LOCALIZATION

Dose -guided RT

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Dose painting (MRI+VMAT+IGRT)

Hypofractionation

Dose escalation in dominant les

ion

Jouyaux, Cancer Radiother 2010

Respect of the dose contraints in the OAR

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IMRT/IGRT for gynaecological cancers

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Increasing the dose in the tumor

Decreasing the dose in the OARs

Minimal TOXICITY

Maximal LOCAL CONTROL

IMRT -IGRT in gyn: goal nb 1= decreasing side effects

-Rectum

-Bladder

-Small bowel

-Bone marrow

Late grade 3 complications:- Small Bowel 3%- Rectum 5%- Bladder 5%- Sigmoid < 0.2%

Cervical cancer

Endometrial cancerVulvar carcinoma

Ovarian cancer

Pelvic, inguinal, lombo-aortic

lymph nodes

+ CDDP

Large target volumes +CDDP

> Grade 3 complications = 10-12% at 10 yrs

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Why IMRT in gynecological malignancies ?

In the upper pelvis:- the small bowel

- the bone marrow

Roeske, IJROBP 2000

In the lower pelvis:- the rectum

- the bladder

- the bone marrow

In the abdomen:- the kidneys

- the small bowel

To spare:

Page 85: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Increasing the dose in the tumor

Decreasing the dose in the OARs

Minimal TOXICITY

Maximal LOCAL CONTROL

Cervical cancer

Endometrial cancer

Vulvar carcinoma

Ovarian cancer

Pelvic, inguinal, lombo-aortic

lymph nodes

IMRT -IGRT in gyn: goal nb 2=improving local control

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To escalate the dose in locally advanced cervical cancer (tumor and nodes)

� PET guided IMRT

Why IMRT in gynecological malignancies ?

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Increasing the dose in the tumor

Maximal LOCAL CONTROL

DOSIMETRIC benefit of IMRT

(/3DCRT) ?Decreasing the dose in the OARs

Minimal TOXICITY

IMRT in gynaecological tumor

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Increasing the dose in the tumor

Maximal LOCAL CONTROL

DOSIMETRIC benefit of IMRT ?

Decreasing the dose in the OARs

Minimal TOXICITY

IMRT reduces the dose to the:

-small bowel

-rectum

-bladder

-bone marrow

-kidney

IMRT in gynaecological tumor

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Mundt, IJROBP 2003

36 gynecological tumor pts

IMRT spares the small bowel

DOSIMETRIC STUDY: standard 3DCRT versus IMRT

IMRT

4 fields

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Increasing the dose in the tumor

Maximal LOCAL CONTROL

DOSIMETRIC benefit of IMRT?

Decreasing the dose in the OARs

Minimal TOXICITY

IMRT reduces the dose to the:

-small bowel

-rectum

-bladder

-bone marrow

-kidney

IMRT in gynaecological tumor

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DOSIMETRIC STUDY: standard 3DCRT versus IMRT

Roeske, IJROBP 2002

10 pts: cervical (5) or endometrial (5)

- CTV: proximal vagina, parametrial tissues, uterus (if present) + regional lymph nodes- PTV: CTV expanded uniformly by 1 cm

4-field box IMRT

45 Gy

average PTV doses: 47.8 Gy 47.4 Gy

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IMRT spares the rectum

DOSIMETRIC STUDY: standard 3DCRT versus IMRT

Roeske, IJROBP 2002

average volume of rectum irradiated at the prescription

dose reduced by 23% (p<0.001)

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Increasing the dose in the tumor

Maximal LOCAL CONTROL

DOSIMETRIC benefit of IMRT ?

Decreasing the dose in the OARs

Minimal TOXICITY

IMRT reduces the dose to the:

-small bowel

-rectum

-bladder

-bone marrow

-kidney

IMRT in gynaecological tumor

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IMRT spares the bladder

DOSIMETRIC STUDY: standard 3DCRT versus IMRT

Roeske, IJROBP 2002

average volume of bladderirradiated at the prescription

dose reduced by 23% (p<0.001)

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Increasing the dose in the tumor

Maximal LOCAL CONTROL

DOSIMETRIC benefit of IMRT?

Decreasing the dose in the OARs

Minimal TOXICITY

IMRT reduces the dose to the:

-small bowel

-rectum

-bladder

-bone marrow

-kidney

IMRT in gynaecological tumor

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Mell, IJROBP 2008

7 pts

AP/PAIMRT 4 field box

7 pts + CDDP

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Mell, IJROBP 2008

Lower pelvic bone marrow

IMRT spares the bone marrow

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Increasing the dose in the tumor

Maximal LOCAL CONTROL

DOSIMETRIC benefit of IMRT?

Decreasing the dose in the OARs

Minimal TOXICITY

IMRT reduces the dose to the:

-small bowel

-rectum

-bladder

-bone marrow

-kidney

IMRT in gynaecological tumor

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Salama, IJROBP 2006

Extendedirradiation to the para-aortic area

IMRT spares the kidneys

- Significant dose reduction to kidneys- No dose level above 18 Gy

2 fields vs 4 fields vs IMRT

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Increasing the dose in the tumor

Maximal LOCAL CONTROL

DOSIMETRIC benefit of IMRT

CLINICAL benefit of IMRT?

Decreasing the dose in the OARs

Minimal TOXICITY

IMRT in gynaecological tumor

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IMRT in gynecological cancer

Clinical experience relatively limited:

- Limited number of series

- Limited number of pts/series

- Limited follow-up

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Increasing the dose in the tumor

Maximal LOCAL CONTROL

CLINICAL benefit of IMRT?

Decreasing the dose in the OARs

Minimal TOXICITY

IMRT reduces the toxicity :

- GI toxicity (acute/late)

- GU toxicity (acute/late)

- hematological

IMRT in gynaecological tumor

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Hasselle, IJROBP 2011

45 Gy in 1.8-Gy daily fractions

111 patients, 3 institutions (2000-2007), all IMRT

Median follow-up = 27 months

Clinical benefit of IMRT in gynecological cancerLocally advanced cervical cancer

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Hasselle, IJROBP 2011

TOXICITY

111 patients, 3 institutions (2000-2007)

Low late toxicity (<3% grade 3 and 4)

Clinical benefit of IMRT in gynecological cancerLocally advanced cervical cancer

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Kidd, IJROBP 2010

Clinical benefit of IMRT in gynecological cancer

Locally advanced cervical cancer

Page 106: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

GI/GU toxicity

Kidd, IJROBP 2010

non IMRT

IMRT

Clinical benefit of IMRT in gynecological cancer

Locally advanced cervical cancer

Page 107: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT for gynecological tumor is safe: provides high local control and survival

Kidd, IJROBP 2010

Locally advanced cervical cancer

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Increasing the dose in the tumor

Maximal LOCAL CONTROL

CLINICAL benefit of IMRT?

Decreasing the dose in the OARs

Minimal TOXICITY

IMRT reduces the toxicity :

- GI toxicity (acute/late)

- GU toxicity (acute/late)

- hematological

IMRT in gynaecological tumor

Page 109: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Brixey, IJROBP 2002

Absolute Neutrophil Count36 pts

Pelvic bone marrow

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Increasing the dose in the tumor

Maximal LOCAL CONTROL

CLINICAL benefit of IMRT ?

Decreasing the dose in the OARs

Minimal TOXICITY

IMRT reduces the toxicity :

- GI toxicity (acute/late)

- GU toxicity (acute/late)

- hematological

IMRT allows new RT indications

IMRT in gynaecological tumor

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Recurrence in the para-aortic nodes

Recurrence in the right common iliac lymph nodes

Eifel, IG-IMRT Springer 2006

IMRT for recurrence (re-irradiation)

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Rochet, BMC Cancer 2007

-Target volume

whole abdomen + (retroperitoneal, para-aortic and pelvic) nodal areas

-Total dose

30 Gy in 1.5 Gy fractions and 4 weeks(5 × 1.5 Gy per week)

8 pts

IMRT allows to irradiate large volumes

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DOSIMETRIC benefit

CLINICAL benefit

Anatomic variations ���� IGRT ?

Cervix and uterus move considerablydue to bladder and rectal filling variations and tumor regression(displacement of the uterine fundus up to 48 mm !!)

IGRT in gynaecological tumor

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- For set-up uncertainties= 5-7 mm (Stroom IJROBP 2000)

- For internal organ motion =10-15 mm (Tyagi IJROBP 2011)

�PTV margins should be around 15 mm

(less for the LN=7 mm)

PTV margins

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IGRT in gynecological tumors: strategies

EPIDs, kV imaging

Bony anatomy registration(minimize the set-up error)

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CBCT, tomotherapyEPIDs, kV imaging

Bony anatomy registration(minimize the set-up error)

Soft tissue visualisation

check the CTV (uterus) inside the PTV

Yes

Treatment

IGRT in gynecological tumors: strategies

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CBCT, tomotherapyEPIDs, kV imaging

Bony anatomy registration(minimize the set-up error)

Soft tissue visualisation

check the CTV (uterus) inside the PTV

Yes<

Treatment

No (and systematic)

Increase PTV margins

Off-line:

IGRT in gynecological tumors: strategies

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CBCT, tomotherapyEPIDs, kV imaging

Bony anatomy registration(minimize the set-up error)

Soft tissue visualisation

check the CTV (uterus) inside the PTV

Adaptive RT (New plan)

Yes

Treatment

No (and systematic)

Increase PTV margins

Off-line:

IGRT in gynecological tumors: strategies

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Stewart IJROBP 2010

2 hypothetical treatment scenarios: - a 3-mm margin plan withno replanning- a 3-mm margin plan with an automatedreplan performed on the updated weeklypatient geometry

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Stewart IJROBP 2010

Weeklyreplanning

improves PTV coverage

No replan

Replan

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Kerkhof, IJROBP 2008

11 cervical cancer patients

-Contours

-6dose levels:

V10Gy,V20Gy,V30Gy,V40Gy, V42.8Gy,V45Gy10-15 mm1 reference IMRT plan

based on the pre-treatmentMRI scan (pre- IMRT)

-Bladder

- rectum

- bowel

- sigmoid:

4 mm4 weekly IMRT plans per pt, based on weekly MRI scans (to simulate an online-IMRT approach).

ComparisonPTV

(primary and nodal)

IMRT plan

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Kerkhof, IJROBP 2008

Online-IMRT in cervix

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Kerkhof, IJROBP 2008

Online IMRT compared to pre-IMRT decreases the dose in the OARs(by decreasing PTV margins)

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Kerkhof, IJROBP 2008

Online IMRT compared to pre-IMRT decreases the dose in the OARs(by decreasing PTV margins)

Interestin

g in theory but how to do

on-line IM

RT in practice ?

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CBCT, tomotherapyEPIDs, kV imaging

Bony anatomy registration(minimize the set-up error)

Soft tissue visualisation

check the CTV (uterus) inside the PTV

Adaptive RT (New plan)

Yes

On-line:

treatment plan library

Treatment

No (and systematic)

Increase PTV margins

Off-line:

IGRT in gynecological tumors: strategies

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Predict uterus/cervix shape and positionbased on bladder filling

Bondar, adiother Oncol 2011

2 series of CT-scans

� customized ITV that could replace the conventional PTV

� adaptive strategybased on a pre-treatment generated treatment plan library

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IMRT in gynecological cancerConclusions

- IMRT experience is relatively limited (nb of series, nb of pts/series, follow-up)

- IMRT compared to 3DCRT provides:

- dosimetric benefit: in rectum/bladder/small bowel/bone marrow

- clinical benefit:

- is safe

- lower acute +late toxicity (GU/GI/hematological)

- new RT indications: whole abdomen RT / re-irradiation

- IGRT: strong rational due to uterus motion, almost no-clinical experience

Cervix cancer +++

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IMRT -IGRT for anal canal

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AP/PA 3D-RT IMRT

Menkarios, Radiation Oncol 2007

10 ptsCTV= tumor, anal canal, inguinal, peri-rectal, and internal/external iliac nodes (+ pre-sacral for T4/N2-3)

45 Gy/25 followed by a 14.4 Gy/8 boost

Dosimetric benefit of IMRT in anal canal ?

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AP/PA 3DCRT IMRT

>

Menkarios, Radiation Oncol 2007

Dosimetric benefit of IMRT in anal canal

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Increasing the dose in the tumor

Maximal LOCAL CONTROL

DOSIMETRIC benefit of IMRT

CLINICAL benefit of IMRT?

Decreasing the dose in the OARs

Minimal TOXICITY

IMRT in anal canal tumor

Page 132: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

53 ptswith anal cancerIMRT: • 45Gy in: GTV, internal/external iliac + inguinal nodal group • + 9 Gy in primary sites and involved nodes

9 equally spaced fields (0, 40, 80, 120, 160, 200, 240, 280, and320 degrees)

+ cc chemo(5FU /mitomycin C)

Salama

Clinical benefit of IMRT in anal canal

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– 58% completed treatment without interruption

– GI toxicity: Grade 3 in 15% with no Grade 4 � Better than RTOG 98-11: 34% had Grade 3 - 4

– Dermatologic: Grade 3 in 38%• Similar to studies with 2-wk treatment breaks� Better than RTOG 98-11: 48%

– Hematologic toxicities: Grade 3 and 4 in 58% of patients� Similar to RTOG 98-11 rates of 60% (however no bone IMRT

constraints)

Salama, JCO 2007

comparison with results from RTOG 98-11 (no IMRT)Concomitant chemo-RT (5-FU/mitomycin) vs.

Induction with 5-FU/Cisplatin followed by concomitant chemo-RT

IMRT in anal canal decreases toxicity

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Carcinologic results

– Complete response: 92%– Local recurrence rate:13% @ 18 months– 18-month colostomy free survival: 83.7%– 18-month distant recurrence free survival:92.3%

Salama

IMRT in anal canal is safe

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Clivio, Radiother Oncol 2010

10 patients

Plans generated for each case:- fixed beam IMRT- single (RA1) + double (RA2)-modulated arcs

Dose prescription: simultaneous integrated boost:- 59.4 Gy to the primary tumour (at 1.8 Gy/fraction) - 49.5 Gy to risk area including inguinal nodes

Planning objectives:-PTV: minimum dose >95%, maximum dose < 107%-OARs:

- bladder (mean < 45 Gy, D2% < 56 Gy, D30% < 35 Gy)- femurs (D2% < 47 Gy)- small bowel (mean < 30 Gy, D2% < 56 Gy)

Static IMRT versus VMAT in anal canal ?

DOSIMETRIC study

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Number of computed MU/fraction:-1531 ± 206 for IMRT- 468 ± 95 for RA1- 545 ± 80 for RA2

Treatment time:- 9.4 ± 1.7 min for IMRT - 1.1 ± 0.0 min for RA1 - 2.6 ± 0.0 min for double arcs

Clivio, Radiother Oncol 2010

Static IMRT versus VMAT in anal canal

/3

/5

Page 137: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Clivio, Radiother Oncol 2010

Dosimetric benefit of arc-IMRT for the bladder/femurs

Page 138: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

IMRT/IGRTin rectal cancer

Page 139: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Dosimetric benefit of IMRT in rectum ?

Mok, Radiation Oncol 2011

10 pts T3 pre-op 45 Gy

Page 140: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Dosimetric benefit of IMRT in rectum

IMRT reduces significantly the dose to the small bowel

Mok, Radiation Oncol 2011

Page 141: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Increasing the dose in the tumor

Maximal LOCAL CONTROL

DOSIMETRIC benefit of IMRT

CLINICAL benefit of IMRT?

Decreasing the dose in the OARs

Minimal TOXICITY

IMRT in rectum tumor

Page 142: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Samuelian, IJROBP 2011

Clinical benefit of IMRT in rectum

50.4 Gy

92 pts

Page 143: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

Samuelian, IJROBP 2011

Page 144: L29 - IMRT and IGRT for Pelvic Abdomen Cancer - De Crevoisier

DOSIMETRIC benefit

CLINICAL benefit

Anatomic variations ���� IGRT ?

IGRT in rectum tumor

� mobility + shape variation of the rectum and the mesorectum

(CT scans, CBCT scans, tomographyscans, cine-MRI, clips)

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IGRT for rectal cancer

Gwynne Clin Oncol 2011

Lee IJROBP 2006

DEnittisIJROBP 2008

Brierley Ann Oncol 2007

TournelIJROBP 2008

Step 1: quantification of anatomic variations and PTV margins

Anisotropic margins

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IGRT for rectal cancer

Gwynne Clin Oncol 2011

Step 2: Define a strategy to correct for the anatomical variations

- Prone position (however set-up variation and discomfort)

- Bony anatomy registration(setup uncertainties)

- Soft tissue visualisation: check the CTV inside the PTV:

-laxatives or rectal enemas(preventive/if distension)

-treatment plan library

-adaptive re-planning

CBCT, tomotherapy

EPIDs, kV imaging

���� Very few clinical results

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IMRT for pancreatic tumors

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Milano, IJROBP 2004

OARs:

Liver

Kidney

Spinal cord

Small bowel

3D CRT IMRT(7 to 9 fields)

6 pts

CTV:- GTV or tumor bed- draining lymphatics (porta-hepatis, pancreaticoduodenal, celiac, and periaortic)

= 45 to 54 Gy

Dosimetric benefit of IMRT in pancreas ?

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Milano, IJROBP 2004

3D4D

IMRT

Dosimetric benefit of IMRT in pancreas

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Yovino, IJROBP 2011

46 pts with pancreatic cancer:

IMRT (50.4 Gy) + concurrent chemo((5-FU +capecitabine)

Clinical benefit of IMRT in pancreas

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Yovino, IJROBP 2011

46 pts with pancreatic cancer: IMRT (50.4 Gy) + concurrent chemo((5-FU +capecitabine)

� acute GI toxicity compared with those from RTOG 97-04 (3DCRT witout IMRT)

Clinical benefit of IMRT in pancreas

>

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IMRT/IGRT in pelvis/abdomen : conclusions

+GI toxicity (acute)- rectum- bladder- bowel- kidney

+pancreas

++++GI toxicity (acute)++rectum

+- GI toxicity- dermato toxicity

- rectum- bladder- bowel- kidney- bone- perineum

++anal canalDigestive

++++endometrium

++++-GU/GI toxicity (acute/late)-hemato toxicity

-local control ?

- rectum- bladder- bowel- kidney- bone- ParaoLN

++cervixGynecol

++++++post-op

++++++++++ pelvic LN

+++ +++++-GU/GI toxicity (acute/late)

- local control

-rectum-bladder-bowel

+++++++« in place »Prostate

ExperienceRationalClinical benefit

Dosimetricbenefit

Experience

IGRTIMRT

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Thank you !

Belle Ile, Bretagne, France